Risk factors and prognosis for corneal ectasia after LASIK

PURPOSE

To review cases of corneal ectasia after laser in situ keratomileusis (LASIK), identify preoperative risk factors, and evaluate methods and success rates of visual rehabilitation for these cases.

DESIGN

Retrospective nonrandomized comparative trial.

PARTICIPANTS

Ten eyes from seven patients identified as developing corneal ectasia after LASIK, 33 previously reported ectasia cases, and two control groups with uneventful LASIK and normal postoperative courses: 100 consecutive cases (first control group), and 100 consecutive cases with high myopia (> 8 diopters [D]) preoperatively (second control group).

METHODS

Retrospective review of preoperative and postoperative data for each case compared with that of previously reported cases and cases with uneventful postoperative courses.

MAIN OUTCOME MEASURES

Preoperative refraction, topographic features, residual stromal bed thickness (RSB), time to the development of ectasia, number of enhancements, final best-corrected visual acuity (BCVA), and method of final correction.

RESULTS

Length of follow-up averaged 23.4 months (range, 6-48 months) after LASIK. Mean time to the development of ectasia averaged 16.3 months (range, 1-45 months). Preoperative refraction averaged -8.69 D compared with -5.37 D for the first control group (P = 0.005). Preoperatively, 88% of ectasia cases met criteria for forme fruste keratoconus, compared with 2% of the first control group (P < 0.0000001) and 4% of the second control group (P = 0.0000001). Seven eyes (70%) had RSB <250 microm, as did 16% of eyes in the first control group and 46% of the second control group. The mean RSB for ectasia cases (222.8 microm) was significantly less than that for the first control group (293.6 micro m, P = 0.0004) and the second control group (256.5 microm; P = 0.04). Seven eyes (70%) had enhancements. Only 10% of eyes lost more than one line of BCVA, and all patients eventually achieved corrected vision of 20/30 or better. One case required penetrating keratoplasty (10%), while all others required rigid gas-permeable contact lenses for correction.

CONCLUSIONS

Significant risk factors for the development of ectasia after LASIK include high myopia, forme fruste keratoconus, and low RSB. All patients had at least one risk factor other than high myopia, and significant differences remained even when controlling for myopia. Multiple enhancements were common among affected cases, but their causative role remains unknown. We did not identify any patients who developed ectasia without recognizable preoperative risk factors.

Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients

To assess the clinical significance of coronary artery ectasia 4993 consecutive coronary arteriograms were reviewed to identify patients with this condition and to allow the assessment of their progress. Coronary ectasia was a relatively uncommon finding (overall incidence 1.4%). It was not related to the development of aortic aneurysms and did not affect the outcome, results of coronary artery surgery, or symptoms.

Posthaemorrhagic ventricular dilatation in the premature infant: natural history and predictors of outcome

OBJECTIVE

To investigate the natural history and predictors of outcome of posthaemorrhagic ventriculomegaly in the very low birthweight (VLBW) infant.

METHODS

All VLBW infants admitted between September 1994 and September 1997 to the neonatal intensive care units of Brigham and Women's Hospital (Boston), Children's Hospital (Boston), and Christchurch Women's Hospital (New Zealand) with germinal matrix intraventricular haemorrhage (IVH) were identified. All charts and ultrasound scans were reviewed to define the natural history and perinatal and/or postnatal factors of value in prediction of the course of posthaemorrhagic ventriculomegaly. Progressive ventricular dilatation (PVD) was defined from the results of serial cranial ultrasound scans.

RESULTS

A total of 248 VLBW infants had evidence of IVH (22% of all VLBW infants, mean (SD) gestational age 26.8 (2.6) weeks). A quarter of the infants exhibited PVD. Spontaneous arrest of PVD occurred without treatment in 38% of infants with PVD. Of the remaining 62% with persistent PVD, 48% received non-surgical treatment only (pharmacological and/or drainage of cerebrospinal fluid by serial lumbar punctures), 34% received surgical treatment with insertion of a ventriculoperitoneal reservoir and/or shunt, and 18% died. The development of PVD after IVH and adverse short term outcome, such as the requirement for surgery, were predicted most strongly by the severity of IVH.

CONCLUSIONS

These data reflect the natural history of PVD in the 1990s and show that, despite a slight reduction in its overall incidence, there appears to be a more aggressive course, with appreciable mortality and morbidity in the extremely premature infant. The major predictor of adverse short term outcome, defined as death or need for surgical intervention, was the severity of IVH. These findings may be valuable for the management of very small premature infants.

Iatrogenic keratectasia after laser in situ keratomileusis for less than -4.0 to -7.0 diopters of myopia

PURPOSE

To study 13 eyes with less than -4.0 to -7.0 diopters of myopia that developed central or inferior keratectasia after laser in situ keratomileusis (LASIK).

METHODS

The progress of the ectasia was determined by a series of pre- and post-LASIK topographies and the case histories.

RESULTS

Progressive ectasia developed from 1 week to 27 months after LASIK. This necessitated the wearing of hard contact lenses or penetrating keratoplasty. One eye improved for some months after photorefractive keratectomy retreatment. Two eyes in 1 patient and 1 eye in a second patient had latent keratoconus before surgery.

CONCLUSION

Laser in situ keratomileusis can cause permanent weakening and ectasia of the cornea even in eyes with low myopia.

Extracorporeal shock-wave lithotripsy of pancreatic calculi

Extracorporeal shock-wave lithotripsy (ESWL) has been used to disintegrate pancreatic stones located in the main pancreatic duct for 123 patients with severe chronic pancreatitis. Endoscopic management following ESWL is aimed at restoring the pancreatic flow to the duodenum. Stone disintegration was achieved in 122 patients, whereas a decrease in the main pancreatic duct diameter resulted in 111, and complete clearance of the main pancreatic duct was obtained in 72. Pain relief, complete (40/88) or partial (35/88), correlated significantly with the results of the endoscopic drainage of the main pancreatic duct (e.g., decrease in main pancreatic duct diameter). Relapsing pain was most often related to recurrent pancreatic duct obstruction. Of 76 patients whose body weight had decreased before ESWL, 54 gained weight. Improvement of the exocrine function, evaluated by the [14C]triolein breath test before and 11 months, on the average, after ESWL, was observed in 12 patients among 22 for whom this test was performed before and after treatment. Improvement of the endocrine function after relief of obstruction of the main pancreatic duct was less frequently recorded (4/41). ESWL of pancreatic stones is a new, safe, and highly effective method of facilitating the endoscopic procedures for relief of pancreatic duct obstruction in severe chronic pancreatitis.

EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy

BACKGROUND

EUS-guided pancreatogastrostomy (EPG) is described as an alternative to surgery for ductal decompression in symptomatic patients when endoscopic transpapillary access of the main pancreatic duct (MPD) is impossible.

OBJECTIVE

To present the midterm clinical response and follow-up of a larger group of patients treated with EPG and a new transbulbar approach, EUS-guided pancreatobulbostomy (EPB).

DESIGN

Retrospective case review.

SETTING

Two tertiary referral centers in Brussels and Marseille.

PATIENTS

From 2000 to 2004, 36 patients (51 years old; range, 14-71 years) were seen.

INTERVENTION

EPG or EPB.

MAIN OUTCOME MEASUREMENTS

Pain relief, technical aspects, complications, and clinical follow-up.

RESULTS

Indications were chronic pancreatitis, with complete obstruction (secondary to a tight stenosis, a stone, or MPD rupture); inaccessible papilla or impossible cannulation (n = 20); anastomotic stenosis after a Whipple procedure (n = 12); complete MPD rupture after acute pancreatitis (AP); or trauma (n = 4). EPG or EPB was unsuccessful in 3 patients; 1 was lost to follow-up. Major complications occurred in 2 patients and included 1 hematoma and 1 severe AP. The median follow-up was 14.5 months (range, 4-55 months). Pain relief was complete or partial in 25 patients (69%, intention to treat). Eight patients treated had no improvement of their symptoms (4 were subsequently diagnosed with cancer). Stent dysfunction occurred in 20 patients (55%) and required a total of 29 repeat endoscopies.

LIMITATIONS

Technically demanding and requires careful pretherapeutic evaluation.

CONCLUSIONS

EPG or EPB appears to be an effective and relatively safe treatment for the management of pain secondary to pancreatic ductal hypertension in patients with an MPD not accessible by a transpapillary route.

Endoscopy in eosinophilic esophagitis: "feline" esophagus and perforation risk

BACKGROUND & AIMS

Idiopathic eosinophilic esophagitis is an underdiagnosed disease with typical endoscopic findings, which have not been well described.

METHODS

Charts and pathology reports at two tertiary care centers from June 1993 to April 2002 were reviewed to describe the endoscopic findings of this disease and to correlate them with clinical characteristics. Eight patients were identified as having eosinophilic esophagitis based on clinical symptoms and pathology reports.

RESULTS

Soft and subtle ring(s) in the esophagus were found in 7 of 8 patients. In 3 of 8 patients, the esophagus appeared rigid. Mucosal rents occurred with simple passage of the endoscope in 5 of 8 patients. One patient developed a perforation after simple passage of the endoscope. Endoscopic findings can be normal or very subtle in these patients, and the findings can easily be missed during endoscopy. Tearing of the esophagus can occur with simple passage of the endoscope or biopsy even in the absence of overt rings. A minimum of 8 weeks of medical therapy (proton pump inhibitor, histamine antagonists, immunosuppressants) should be undertaken before considering dilation because of the high risk involved with the procedure and the good response to medical therapy.

CONCLUSIONS

We recommend considering dilation only in patients with eosinophilic esophagitis who do not respond to medical therapy and have rings that appear to be obstructing the lumen.

One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study

OBJECTIVE

To evaluate whether 1 week of ciprofloxacin before percutaneous nephrolithotomy (PCNL) in patients with stones of > or = 20 mm or pelvicalyceal dilatation, reduces urosepsis, as we previously reported that such patients have four times the risk of urosepsis after PCNL.

PATIENTS AND METHODS

Patients undergoing PCNL, and who fulfilled strict selection criteria, were recruited prospectively into a study which was conducted in two phases. The study methods were similar to those previously described; patients with dilated pelvicalyceal systems and/or stones of > or = 20 mm from phase 1 (previously published) acted as controls. In the subsequent phase, the same selection criteria applied and only those with stones of > or = 20 mm and/or dilated pelvicalyceal systems were given ciprofloxacin 250 mg twice daily for 1 week before PCNL and comprised the treatment arm. Midstream urine samples, renal pelvic urine and fragmented stones were collected to assess culture and sensitivity. Systemic inflammatory response syndrome (SIRS) was used to define urosepsis after PCNL. The urologists monitoring the patients after PCNL and conducting the analysis were all unaware of the characteristics of the stones or intravenous urography findings before PCNL. In all, 115 patients (54 in phase 1 and 61 in phase 2) were recruited, of whom 46 in phase 1 and 52 in phase 2 had stones of > or = 20 mm and/or a dilated pelvicalyceal system, and became the control and treatment arms, respectively.

RESULTS

The patient demographics were similar in both arms. There was three times less risk of upper tract infection (relative risk 3.4, 95% confidence interval 1.0-11.8, P = 0.04) and SIRS (2.9, 1.3-6.3, P = 0.004) in the patients receiving ciprofloxacin (treatment arm).

CONCLUSIONS

The administration of oral ciprofloxacin for 1 week before PCNL in patients with stones of > or = 20 mm or dilated pelvicalyceal systems significantly reduced the risk of urosepsis.

Natural history of cardiovascular manifestations in Marfan syndrome

AIMS

To investigate the natural history of mitral valve and aortic abnormalities in patients with Marfan syndrome during childhood and adolescence.

METHODS

Fifty two patients with Marfan syndrome were followed for a mean of 7.9 years. Occurrence of adverse cardiovascular outcomes was measured clinically and by ultrasound examination.

RESULTS

Mitral valve prolapse (MVP) was diagnosed in 46 patients at a mean age of 9.7 years, more than 80% of whom presented as "silent MVP". Mitral regurgitation (MR) occurred in 25 patients, aortic dilatation in 43, and aortic regurgitation (AR) in 13. Both MVP and aortic dilatation developed at a constant rate during the age period 5-20 years. In 23 patients MVP was diagnosed before aortic dilatation, in 18 the reverse occurred, and in 11 patients the two abnormalities were diagnosed simultaneously. During follow up, 21 patients showed progression of mitral valve dysfunction; progression of aortic abnormalities occurred in 13. Aortic surgery was performed in 10; two died of subsequent complications. Mitral valve surgery was performed in six. In sporadic female Marfan patients the age at initial diagnosis of MVP, MR, aortic dilatation, and AR was lowest, the grade of MR and AR most severe, the time lapse between the occurrence of MVP and subsequent MR as well as between dilatation and subsequent AR shortest, and the risk for cardiovascular associated morbidity and mortality highest.

CONCLUSIONS

During childhood and adolescence in Marfan syndrome, mitral valve dysfunction as well as aortic abnormalities develop and progress gradually, often without symptoms, but may cause considerable morbidity and mortality by the end of the second decade, especially in female sporadic patients.

Changing concepts in management of primary obstructive megaureter

The management of neonatal urinary tract dilatations represents one of the most challenging dilemmas in pediatric urology today. We have been confronted with 44 renal units in 35 neonates diagnosed as having primary obstructive megaureter during the last 6 years. Of these units 23 in 17 infants were diagnosed antenatally and 20 (87 per cent) have been managed without surgical intervention. Notably, 16 renal units were graded as moderate to severe megaureters by an excretory urogram. The decision to manage conservatively was based on the initial extraction of the 99mdiethylenetriaminepentaacetic acid renal scan (the extraction factor). This estimate of absolute renal function has been used to differentiate dilatations with obstructive implications for the renal parenchyma from those without. Significantly, expectant treatment has resulted in improvement of dilatation on sequential excretory urograms in 15 megaureters and none has shown a deterioration of function by renal scan. Similar diagnostic criterion also has resulted in conservative management for 12 of 21 additional neonatal megaureters seen during this period with symptoms or they were discovered serendipitously. Only 2 of these 12 megaureters required surgical correction. The neonatal primary megaureter appears in many cases to represent a different entity than those that commonly presented before the advent of antenatal and perinatal diagnosis.

Primary dilated megaureter: long-term followup

Previously, we reported on the changing concepts in the management of 35 neonates with primary obstructive megaureters, 25 of whom were observed without surgery for a mean of 28 months while 10 were surgically treated. We report the long-term outcome of the 25 patients who were managed without surgery. This group consists of 19 male and 6 female neonates with 19 unilateral and 6 bilateral dilated ureters. Of the patients 17 presented with an antenatal diagnosis of hydronephrosis, 2 with infection and 6 with incidental findings. None of the patients had vesicoureteral reflux. Followup serial imaging (2 or more studies per case) consisted of excretory urography in 18 of the 25 cases, diethylenetriaminepentaacetic acid renal scan in 16 and/or sonogram in 10. Mean followup was 7.3 years (range 4.8 to 12.4) for 24 patients and 1 was lost to followup after 1.5 years. Excretory urography showed improvement in urinary tract dilatation in 12 cases and stable dilatation in 6. Renal scans demonstrated expected interval increases in the glomerular filtration rate with age without any deterioration in per cent of renal function in all 16 cases. None of the patients had stones, pain or pyelonephritis. We conclude that it is safe to follow a select group of patients with primary dilated megaureters in the absence of vesicoureteral reflux. We recommend antibiotic prophylaxis and serial urinary tract imaging to confirm renal growth and preservation of renal function.

Laryngoceles and saccular cysts in infants and children

Laryngoceles and saccular cysts are an unusual cause of respiratory obstruction in infants and children. Laryngoceles in particular are less common in the pediatric population than in adults. They typically produce intermittent upper airway obstruction and hoarseness (due to episodic filling with air), and are, therefore, difficult to diagnose. Saccular cysts produce similar symptoms but are not episodic. While smaller anterior saccular cysts are readily managed by endoscopic excision, larger saccular cysts tend to recur repeatedly. Review of experience with 20 infants and children having saccular pathologic changes (17 saccular cysts and three laryngoceles) suggests that saccular lesions are more troublesome than is generally appreciated. The clinical course is typically a lengthy one, with multiple endoscopic procedures. Most patients required tracheotomy, some under emergent conditions. Three patients acquired subglottic stenosis; one was clinically significant. A fourth patient had a congenital subglottic stenosis. Saccular cysts can be managed endoscopically in many cases, but if persistent after two or three endoscopic procedures, a prolonged course can be anticipated. Complete excision, endoscopically or through an external surgical approach, may shorten the clinical course.

Idiopathic megacolon: a review of 42 cases

Forty-two patients with idiopathic megacolon who were seen at St Mark's Hospital over an 18-year period are reviewed with regard to presentation, investigation and management. The differential diagnosis is discussed with particular reference to Hirschsprung's disease. The important aspects of medical treatment are outlined and the possible reasons for failure in more than one-half of the patients are discussed. The indications for surgical intervention in 14 patients are reviewed. The results following subtotal colectomy were better than following a localized sigmoid resection.

Aortic root dilatation in tetralogy of Fallot long-term after repair—histology of the aorta in tetralogy of Fallot: evidence of intrinsic aortopathy

The ascending aorta or pulmonary trunk in congenital heart disease may dilate out of proportion to hemodynamic or morphogenetic expectations, may become aneurysmal, and may rupture. A bicuspid aortic valve and/or coarctation of the aorta are consistently associated with ascending aortic and para-coarctation medial abnormalities. Congenital heart diseases such as single ventricle, truncus arteriosus, transposition of the great arteries and tetralogy of Fallot are also associated with aortic medial abnormalities. Aortic regurgitation in unrepaired tetralogy of Fallot imposes volume overload on both ventricles. A significant subset of adults late after repair of tetralogy of Fallot exhibits progressive aortic root dilatation which may lead to regurgitation and predispose to dissection and rupture which can be fatal, and necessitating aortic valve and aortic root surgery. The aortic dilatation relates medial abnormalities coupled with previous long-standing volume overload of the ascending aorta. Risk factors for aortic dilatation and regurgitation in tetralogy of Fallot relate to specific hemodynamic abnormalities such as pulmonary atresia, right aortic arch and a history of an aorto-pulmonary shunt, and patient demographics such as male sex and the association of chromosome 22q11 deletion. There is no current consensus on beta-blocker administration for limiting progressive dilatation of the aortic root in patients with congenital heart disease and repaired tetralogy of Fallot. Aortic root surgery should be considered for these patients and address aortic regurgitation and or prevent the risk of aortic dissection. Meticulous follow-up of the aortic root after repair, tetralogy of Fallot are thus recommended.

Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation: results at 30 months. Ventriculomegaly Trial Group

One hundred and fifty seven infants with progressive ventricular dilatation after intraventricular haemorrhage were randomised to either early repeated cerebrospinal fluid tapping or conservative management. Thirty two (20%) infants died and 13 (8%) were lost to follow up. One hundred and twelve children (90% of survivors) were examined at 30 months by a single experienced examiner. Overall, 54 (48%) scored less than 70 on the Griffiths developmental scales, 101 (90%) had neuromotor impairment, and 85 (76%) had marked disability; 63 (56%) had multiple impairments. Vision was severely affected in 10 (9%) and 30 (27%) had a field defect. Six per cent (seven children) had sensorineural hearing loss and 16 (14%) were taking regular anticonvulsant drugs. Although early cerebrospinal fluid tapping reduced the rate of ventricular and head expansion, there was no statistically significant difference (at the 5% level) between the treatment groups in the prevalence of neuromotor impairments, non-neuromotor impairments, nor multiple impairments at 30 months. These findings were consistent regardless of the presence or absence of a parenchymal cerebral lesion at entry to the trial. In the light of these findings and the 7% risk of cerebrospinal fluid infection associated with repeated tapping, this form of early intervention cannot be recommended.

Cowper's syringocele: symptoms, classification and treatment of an unappreciated problem

PURPOSE

Cowper's syringocele is a rare deformity in the male urethra that is a distention of the duct of the bulbourethral (Cowper's) gland. We report on 7 cases, review the symptoms and pathophysiology, and propose a simplified classification of this uncommon lesion.

MATERIALS AND METHODS

We reviewed 7 cases of Cowper's syringocele diagnosed from 1997 to 1998 at our hospital.

RESULTS

Cowper's syringocele was diagnosed in 7 patients 25 to 51 years old with persistent post-void dribbling, frequency, urethral pain, hematuria or sudden urethral discharge. Diagnosis was made with urethrocystoscopy or retrograde urethrogram. Cowper's syringocele may be closed (a distended cyst-like swelling in the wall of the urethra) or open (an opening enabling urine reflux into the syringocele). In 2 patients asymptomatic open syringocele was diagnosed. In 1 patient symptomatic syringocele resolved spontaneously following an infection. In 4 patients open syringocele was treated with transurethral marsupialization because of persistent post-void dribbling. Postoperatively patients were completely symptom-free with a mean followup of 12 months (range 6 to 23).

CONCLUSIONS

Cowper's syringocele may be more common than currently realized. Urologists should rule out this possibility in young male patients with lower urinary tract symptoms and persistent post-void dribbling as it can be treated easily.

Clinical and histologic evaluation of psoriatic plaques treated with a flashlamp pulsed dye laser

BACKGROUND

Psoriatic plaques can be cleared by destruction of the dermal papillae. Dilated vessels, the major component of psoriatic dermal papillae, can be selectively destroyed with yellow light lasers. Previous investigators have demonstrated partial clearing of psoriatic plaques after treatment with a pulsed dye laser (PDL) (585 nm).

OBJECTIVE

This study was designed to examine the clinical and histologic events of psoriasis treated with the PDL.

METHODS

Psoriatic plaques were treated with a short (450 microseconds) and long (1500 microseconds) pulse-width PDL. Photographs of the plaques were used for clinical assessment. Biopsy specimens were examined microscopically.

RESULTS

Significant clinical improvement was seen, and no significant difference between the long and short pulse-width lasers was found. Patients responding to treatment with the PDL remained in remission for up to 13 months. Histologic normalization occurred after treatment. Two pretreatment vascular patterns were seen: vertically oriented vessels with few horizontal vessels and numerous tortuous vessels. Tortuous vessels were associated with poor clinical results.

CONCLUSION

The PDL can induce prolonged remission in chronic plaque psoriasis. The vascular pattern may help to distinguish those patients likely to respond to this treatment.

Upregulation of elastase proteins results in aortic dilatation in mucopolysaccharidosis I mice

Mucopolysaccharidosis I (MPS I), known as Hurler syndrome in the severe form, is a lysosomal storage disease due to alpha-L-iduronidase (IDUA) deficiency. It results in fragmentation of elastin fibers in the aorta and heart valves via mechanisms that are unclear, but may result from the accumulation of the glycosaminoglycans heparan and dermatan sulfate. Elastin fragmentation causes aortic dilatation and valvular insufficiency, which can result in cardiovascular disease. The pathophysiology of aortic disease was evaluated in MPS I mice. MPS I mice have normal elastic fiber structure and aortic compliance at early ages, which suggests that elastin assembly is normal. Elastin fragmentation and aortic dilatation are severe at 6 months, which is temporally associated with marked increases in mRNA and enzyme activity for two elastin-degrading proteins, matrix metalloproteinase-12 (MMP-12) and cathepsin S. Upregulation of these genes likely involves activation of STAT proteins, which may be induced by structural stress to smooth muscle cells from accumulation of glycosaminoglycans in lysosomes. Neonatal intravenous injection of a retroviral vector normalized MMP-12 and cathepsin S mRNA levels and prevented aortic disease. We conclude that aortic dilatation in MPS I mice is likely due to degradation of elastin by MMP-12 and/or cathepsin S. This aspect of disease might be ameliorated by inhibition of the signal transduction pathways that upregulate expression of elastase proteins, or by inhibition of elastase activity. This could result in a treatment for patients with MPS I, and might reduce aortic aneurism formation in other disorders.

Posthaemorrhagic ventricular dilatation

Posthaemorrhagic ventricular dilatation is the most serious direct complication of intraventricular haemorrhage after preterm birth. It results initially from multiple small blood clots throughout the cerebrospinal fluid channels impeding circulation and reabsorption. Management is difficult and new treatment approaches are needed.

Iatrogenic keratectasia after a deep primary keratotomy during laser in situ keratomileusis

PURPOSE

To describe a case of keratectasia after a deep primary keratotomy during an aborted laser in situ keratomileusis procedure.

METHODS

Retrospective, observational case report.

RESULTS

In a 47-year-old woman, progressive keratectasia developed after a 90% depth keratotomy during an aborted laser in situ keratomileusis procedure. This case was managed with a rigid gas permeable contact lens and consideration for penetrating keratoplasty.

CONCLUSION

Keratectasia is a reported microkeratome-related complication after laser in situ keratomileusis. Appropriate microkeratome assembly and surgeon awareness are necessary to avoid this complication.

Toxic megacolon: the knee-elbow position relieves bowel distension

Toxic megacolon complicating inflammatory or infective colitis carries a high morbidity and mortality and surgical intervention is necessary in up to 80% of cases. Perforation complicates toxic megacolon in about 35% of cases. After perforation, the death rate nears 50%. Gaseous distension of the bowel causes considerable discomfort to the patient and increases transmural pressure. The latter is thought to cause a reduction in blood flow and may predispose to perforation. The use of instruments for colonic aspiration is discouraged, because of the high risk of perforation. The successful use of the knee-elbow position to relieve bowel distension in two patients with toxic megacolon is described.

Selective salpingography and fallopian tube recanalization

Obstruction of the uterine (proximal) end of the fallopian tube is noted on up to 20% of hysterosalpingograms and has a variety of underlying causes. Definitive diagnosis and treatment in the past have required laparoscopy or laparotomy with tubal resection. Selective salpingography and fallopian tube recanalization with fluoroscopically guided catheters has emerged as an improved method both for diagnosis and treatment in these patients. Technical success rates for overcoming the obstruction and visualizing distal tubal anatomy range from 76% to 95%. Pregnancy rates after the procedure vary depending on the patient populations studied; however, early results indicate a greater than 50% intrauterine pregnancy rate by 1 year. The rate of ectopic pregnancy is approximately 10% and that of early tubal reocclusion is less than 30%. Selective salpingography and fallopian tube recanalization is recommended as the first intervention in patients with obstruction of the proximal fallopian tube.

Extracorporeal Shock Wave Lithotripsy in the Treatment of Proximal Ureteral Stones: Does the Presence and Degree of Hydronephrosis Affect Success?

OBJECTIVES

We investigated the relation between the presence and degree of stone induced hydronephrosis and the outcome of extracorporeal shock wave lithotripsy (SWL) in patients with solitary proximal ureteral stones.

METHODS

130 patients with or without hydronephrosis were treated with SWL. The degree of hydronephrosis was defined by renal ultrasound. Patients were divided into four groups according to the degree of stone induced hydronephrosis. Group 0 (24%) had no urinary system dilatation, group 1 (31.2%) had a mild dilatation of the renal pelvis, group 2 (40%) had a moderate and group 3 (4.8%) a severe dilatation of the renal pelvis and calices. The stone size, number of shock waves applied and number of sessions required to achieve stone clearance were recorded.

RESULTS

Mean stone size was 8.2 mm+/-2.5 mm. Mean time to stone clearance was 13.7 days+/-16.3. In 74.4% of patients stone clearance was observed. Additional 4.8% harbored residual fragments < or =3 mm after 3 months. Differences among the four groups in terms of stone size, time to stone clearance and treatment failure were not significant.

CONCLUSIONS

The presence or degree of hydronephrosis caused by a proximal ureteral stone does not affect the time to stone clearance or success rate after SWL.